Provider First Line Business Practice Location Address:
1186 LAWRENCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48202-1029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-215-3181
Provider Business Practice Location Address Fax Number:
313-731-7656
Provider Enumeration Date:
02/24/2014